Inadequate fluid intake and output monitoring

“The nursing home did not have sterile replacement catheters in stock, despite being aware that Mr [name redacted] had difficulties with his catheter, which had necessitated it being replaced twice in the previous weeks. The mistakes made in ordering placements had not been detected by managers in the nursing home.”

“after Mr [name redacted]' death, weekly stock checks were implemented at Copperfields in order to ensure a sufficient level of stock is maintained at all times.”

“The EMAR system also has a Dashboard that flags an alert in the event any stock is running low. The levels of stock are therefore no longer dependent on visual assessment although, as explained by Ms , weekly visual stock checks still take place”

“A new Registered Home Manager and new Clinical Nurse [name redacted] are now in place. In addition, a second full time Clinical Nurse [name redacted] and a full time Head of Care have been employed.”

“specific steps have also been taken to ensure greater management overview, and quality assurance, of record keeping and documentation. During Mr [name redacted]' residence at Copperfields the relevant governance processes (EQA- Exemplar Quality Assurance) were paper based. However, the majority ofthe EQA processes have now been moved to a digital platform.”

“The individual team leaders have been trained that they are responsible for ensuring that there are no gaps in the supplementary documentation, that all documentation is complete before the end of their shifts and that this is reported to the unit managers, who in turn report it in a daily "take 20 meeting”